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IMPACT STATEMENT - The development of autograft extenders is a significant clinical need in bone tissue engineering. We report new settable poly(thioketal urethane)-based autograft extenders that have bone-like mechanical properties and handling properties comparable to calcium phosphate bone cements. These settable autograft extenders remodeled to form new bone in a biologically stringent intertransverse process model of bone formation that does not heal when treated with calcium phosphate bone void fillers or cements alone. This is the first study to report settable autograft extenders with bone-like strength and handling properties comparable to ceramic bone cements, which have the potential to improve treatment of bone fractures and other orthopedic conditions.
OBJECTIVE - The objective of this study was to test the hypothesis that a compression-resistant bone graft augmented with recombinant human morphogenetic protein-2 (rhBMP-2) will promote lateral ridge augmentation without the use of protective mesh in a canine model.
MATERIALS & METHODS - Compression-resistant (CR) bone grafts were evaluated in a canine model of lateral ridge augmentation. Bilateral, right trapezoidal prism-shaped defects (13-14 mm long × 8-9 mm wide × 3-4 mm deep at the base) in 13 hounds (two defects per hound) were treated with one of four groups: (i) absorbable collagen sponge + 400 μg rhBMP-2/ml (ACS, clinical control) protected by titanium mesh, (ii) CR without rhBMP-2 (CR, negative control), (iii) CR + 200 μg rhBMP-2 (CR-L), or (iv) CR + 400 μg rhBMP-2 (CR-H). All animals were euthanized after 16 weeks. Ridge height and width and new bone formation were assessed by μCT, histology, and histomorphometry. The release kinetics of rhBMP-2 from CR bone grafts in vitro and in vivo in a femoral condyle defect model in rabbits was also evaluated.
RESULTS - All four bone grafts promoted new bone formation (11-31.6 volume%) in the lateral ridge defects. For CR grafts, ridge height and width increased in a dose-responsive manner with increasing rhBMP-2 concentration. Ridge height and width measured for CR-H without the use of protective mesh was comparable to that measured for ACS with a protective mesh.
CONCLUSIONS - At the same dose of rhBMP-2, an injectable, compression-resistant bone graft resulted in a comparable volume of new bone formation with the clinical control (ACS). These findings highlight the potential of compression-resistant bone grafts without the use of protective mesh for lateral ridge augmentation.
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Bone fractures at weight-bearing sites are challenging to treat due to the difficulty in maintaining articular congruency. An ideal biomaterial for fracture repair near articulating joints sets rapidly after implantation, stabilizes the fracture with minimal rigid implants, stimulates new bone formation, and remodels at a rate that maintains osseous integrity. Consequently, the design of biomaterials that mechanically stabilize fractures while remodeling to form new bone is an unmet challenge in bone tissue engineering. In this study, we investigated remodeling of resorbable bone cements in a stringent model of mechanically loaded tibial plateau defects in sheep. Nanocrystalline hydroxyapatite-poly(ester urethane) (nHA-PEUR) hybrid polymers were augmented with either ceramic granules (85% β-tricalcium phosphate/15% hydroxyapatite, CG) or a blend of CG and bioactive glass (BG) particles to form a settable bone cement. The initial compressive strength and fatigue properties of the cements were comparable to those of non-resorbable poly(methyl methacrylate) bone cement. In animals that tolerated the initial few weeks of early weight-bearing, CG/nHA-PEUR cements mechanically stabilized the tibial plateau defects and remodeled to form new bone at 16 weeks. In contrast, cements incorporating BG particles resorbed with fibrous tissue filling the defect. Furthermore, CG/nHA-PEUR cements remodeled significantly faster at the full weight-bearing tibial plateau site compared to the mechanically protected femoral condyle site in the same animal. These findings are the first to report a settable bone cement that remodels to form new bone while providing mechanical stability in a stringent large animal model of weight-bearing bone defects near an articulating joint.
Copyright © 2018 Elsevier Ltd. All rights reserved.
BACKGROUND - The challenging biological and mechanical environment of posterolateral fusion (PLF) requires a carrier that spans the transverse processes and resists the compressive forces of the posterior musculature. The less traumatic posterolateral approach enabled by minimally invasive surgical techniques has prompted investigations into alternative rhBMP-2 carriers that are injectable, settable, and compression-resistant. In this pilot study, we investigated injectable low-viscosity (LV) polymer/composite bone grafts as compression-resistant carriers for rhBMP-2 in a single-level rabbit PLF model.
METHODS - LV grafts were augmented with ceramic microparticles: (1) hydrolytically degradable bioactive glass (BG), or (2) cell-degradable 85% β-tricalcium phosphate/15% hydroxyapatite (CM). Material properties, such as pore size, viscosity, working time, and bulk modulus upon curing, were measured for each LV polymer/ceramic material. An in vivo model of posterolateral fusion in a rabbit was used to assess the grafts' capability to encourage spinal fusion.
RESULTS - These materials maintained a working time between 9.6 and 10.3 min, with a final bulk modulus between 1.2 and 3.1 MPa. The LV polymer/composite bone grafts released 55% of their rhBMP-2 over a 14-day period. As assessed by manual palpation in vivo, fusion was achieved in all (n = 3) animals treated with LV/BG or LV/CM carriers incorporating 430 μg rhBMP-2/ml. Images of μCT and histological sections revealed evidence of bone fusion near the transverse processes.
CONCLUSION - This study highlights the potential of LV grafts as injectable and compression-resistant rhBMP-2 carriers for posterolateral spinal fusion.
BACKGROUND - Infectious complications of musculoskeletal trauma are an important factor contributing to patient morbidity. Biofilm-dispersive bone grafts augmented with D-amino acids (D-AAs) prevent biofilm formation in vitro and in vivo, but the effects of D-AAs on osteocompatibility and new bone formation have not been investigated.
QUESTIONS/PURPOSES - We asked: (1) Do D-AAs hinder osteoblast and osteoclast differentiation in vitro? (2) Does local delivery of D-AAs from low-viscosity bone grafts inhibit new bone formation in a large-animal model?
METHODS - Methicillin-sensitive Staphylococcus aureus and methicillin-resistant S aureus clinical isolates, mouse bone marrow stromal cells, and osteoclast precursor cells were treated with an equal mass (1:1:1) mixture of D-Pro:D-Met:D-Phe. The effects of the D-AA dose on biofilm inhibition (n = 4), biofilm dispersion (n = 4), and bone marrow stromal cell proliferation (n = 3) were quantitatively measured by crystal violet staining. Osteoblast differentiation was quantitatively assessed by alkaline phosphatase staining, von Kossa staining, and quantitative reverse transcription for the osteogenic factors a1Col1 and Ocn (n = 3). Osteoclast differentiation was quantitatively measured by tartrate-resistant acid phosphatase staining (n = 3). Bone grafts augmented with 0 or 200 mmol/L D-AAs were injected in ovine femoral condyle defects in four sheep. New bone formation was evaluated by μCT and histology 4 months later. An a priori power analysis indicated that a sample size of four would detect a 7.5% difference of bone volume/total volume between groups assuming a mean and SD of 30% and 5%, respectively, with a power of 80% and an alpha level of 0.05 using a two-tailed t-test between the means of two independent samples.
RESULTS - Bone marrow stromal cell proliferation, osteoblast differentiation, and osteoclast differentiation were inhibited at D-AAs concentrations of 27 mmol/L or greater in a dose-responsive manner in vitro (p < 0.05). In methicillin-sensitive and methicillin-resistant S aureus clinical isolates, D-AAs inhibited biofilm formation at concentrations of 13.5 mmol/L or greater in vitro (p < 0.05). Local delivery of D-AAs from low-viscosity grafts did not inhibit new bone formation in a large-animal model pilot study (0 mmol/L D-AAs: bone volume/total volume = 26.9% ± 4.1%; 200 mmol/L D-AAs: bone volume/total volume = 28.3% ± 15.4%; mean difference with 95% CI = -1.4; p = 0.13).
CONCLUSIONS - D-AAs inhibit biofilm formation, bone marrow stromal cell proliferation, osteoblast differentiation, and osteoclast differentiation in vitro in a dose-responsive manner. Local delivery of D-AAs from bone grafts did not inhibit new bone formation in vivo at clinically relevant doses.
CLINICAL RELEVANCE - Local delivery of D-AAs is an effective antibiofilm strategy that does not appear to inhibit bone repair. Longitudinal studies investigating bacterial burden, bone formation, and bone remodeling in contaminated defects as a function of D-AA dose are required to further support the use of D-AAs in the clinical management of infected open fractures.
Established clinical approaches to treat bone voids include the implantation of autograft or allograft bone, ceramics, and other bone void fillers (BVFs). Composites prepared from lysine-derived polyurethanes and allograft bone can be injected as a reactive liquid and set to yield BVFs with mechanical strength comparable to trabecular bone. In this study, we investigated the effects of porosity, allograft particle size, and matrix mineralization on remodeling of injectable and settable allograft/polymer composites in a rabbit femoral condyle plug defect model. Both low viscosity and high viscosity grafts incorporating small (<105 μm) particles only partially healed at 12 weeks, and the addition of 10% demineralized bone matrix did not enhance healing. In contrast, composite grafts with large (105-500 μm) allograft particles healed at 12 weeks postimplantation, as evidenced by radial μCT and histomorphometric analysis. This study highlights particle size and surface connectivity as influential parameters regulating the remodeling of composite bone scaffolds.
© 2015 Wiley Periodicals, Inc.
Healing fractures resulting from osteoporosis or cancer remains a significant clinical challenge. In these populations, healing is often impaired not only due to age and disease, but also by other therapeutic interventions such as radiation, steroids, and chemotherapy. Despite substantial improvements in the treatment of osteoporosis over the last few decades, osteoporotic fractures are still a major clinical challenge in the elderly population due to impaired healing. Similar fractures with impaired healing are also prevalent in cancer patients, especially those with tumor growing in bone. Treatment options for cancer patients are further complicated by the fact that bone anabolic therapies are contraindicated in patients with tumors. Therefore, many patients undergo surgery to repair the fracture, and bone grafts are often used to stabilize orthopedic implants and provide a scaffold for ingrowth of new bone. Both synthetic and naturally occurring biomaterials have been investigated as bone grafts for repair of osteoporotic fractures, including calcium phosphate bone cements, resorbable polymers, and allograft or autograft bone. In order to re-establish normal bone repair, bone grafts have been augmented with anabolic agents, such as mesenchymal stem cells or recombinant human bone morphogenetic protein-2. These developing approaches to bone grafting are anticipated to improve the clinical management of osteoporotic and cancer-induced fractures.
OBJECTIVE - The myeloid translocation genes (MTGs) are transcriptional corepressors with both Mtg8(-/-) and Mtgr1(-/-) mice showing developmental and/or differentiation defects in the intestine. We sought to determine the role of MTG16 in intestinal integrity.
METHODS - Baseline and stress induced colonic phenotypes were examined in Mtg16(-/-) mice. To unmask phenotypes, we treated Mtg16(-/-) mice with dextran sodium sulphate (DSS) or infected them with Citrobacter rodentium and the colons were examined for ulceration and for changes in proliferation, apoptosis and inflammation.
RESULTS - Mtg16(-/-) mice have altered immune subsets, suggesting priming towards Th1 responses. Mtg16(-/-) mice developed increased weight loss, diarrhoea, mortality and histological colitis and there were increased innate (Gr1(+), F4/80(+), CD11c(+) and MHCII(+); CD11c(+)) and Th1 adaptive (CD4) immune cells in Mtg16(-/-) colons after DSS treatment. Additionally, there was increased apoptosis and a compensatory increased proliferation in Mtg16(-/-) colons. Compared with wild-type mice, Mtg16(-/-) mice exhibited increased colonic CD4;IFN-γ cells in vehicle-treated and DSS-treated mice. Adoptive transfer of wild-type marrow into Mtg16(-/-) recipients did not rescue the Mtg16(-/-) injury phenotype. Isolated colonic epithelial cells from DSS-treated Mtg16(-/-) mice exhibited increased KC (Cxcl1) mRNA expression when compared with wild-type mice. Mtg16(-/-) mice infected with C rodentium had more severe colitis and greater bacterial colonisation. Last, MTG16 mRNA levels were reduced in human ulcerative colitis versus normal colon tissues.
CONCLUSIONS - These observations indicate that MTG16 is critical for colonocyte survival and regeneration in response to intestinal injury and provide evidence that this transcriptional corepressor regulates inflammatory recruitment in response to injury.
INTRODUCTION - Open fractures are plagued by high complication rates, among which infection and nonunion are the most common, leading to higher morbidity and poor patient outcomes. Despite meticulous surgical care and employment of adjunctive therapies, infection rates remain at 20%, due to the limitations of conventional therapies.
AREAS COVERED - Persistent bacteria often survive initial debridement and treatment with antibiotics. Thus, the bone graft subsequently implanted to promote healing can be the nidus for infection. The principles of biofilm theory and the "race to the surface" have been applied to develop dual-purpose bone grafts that are protected by a sustained release of an antibiotic, thereby preventing bacterial colonization. A simultaneous sustained release of a recombinant human growth factor allows the defect to become vascularized and heal.
EXPERT OPINION - Current therapies fail to meet the challenges of open fractures. Tissue engineering and drug delivery approaches can address the challenges of healing large bone defects while protecting the implant from infection. When combined as an adjunctive therapy with existing clinical practices for management of open fractures, dual-purpose bone grafts that release both an antibiotic and a growth factor at biologically relevant time scales can potentially reduce infection rates and improve patient outcomes.
OBJECTIVE - To determine if a dual-purpose bone graft can regenerate bone and reduce infection in highly contaminated bone critical size defects in rats.
METHODS - Biodegradable polyurethane (PUR) scaffolds were loaded with recombinant human bone morphogenetic protein-2 (BMP-2) and vancomycin (Vanc). The release kinetics of the BMP-2 were tuned to take advantage of its mechanism of action (ie, an initial burst to recruit cells and sustained release to induce differentiation of the migrating cells). The Vanc release kinetics were designed to protect the graft from contamination until it is vascularized by having a burst for a week and remaining well over the minimum inhibitory concentration for Staphylococcus aureus for 2 months. The bone regeneration and infection reduction capability of these dual-purpose grafts (PUR+Vanc+BMP-2) were compared with collagen sponges loaded with BMP-2 (collagen+BMP-2) and PUR+BMP-2 in infected critical size rat femoral segmental defects.
RESULTS - The dual-delivery approach resulted in substantially more new bone formation and a modest improvement in infection than PUR+BMP-2 and collagen+BMP-2 treatments.
CONCLUSIONS - The PUR bone graft is injectable, provides a more sustained release of BMP-2 than the collagen sponge, and can release antibiotics for more than 8 weeks. Thus, the dual-delivery approach may improve patient outcomes of open fractures by protecting the osteoinductive graft from colonization until vascularization occurs. In addition, the more optimal release kinetics of BMP-2 may reduce nonunions and the amount of growth factor required.